Bacterial and viral etiology of severe infection in children less than three months old in the highlands of Papua New Guinea.

OBJECTIVE: Determine the bacterial and viral etiology of severe infection in young Papua New Guinean infants as part of a multicenter study in four developing countries aimed at improving case management guidelines. METHODS: Between March, 1991, and April, 1993, children aged <3 months were recruited at the outpatient department of Goroka Base Hospital, Papua New Guinea (PNG). Children with pre-defined inclusion criteria were enrolled, a history was taken and clinical examination was performed. Blood and urine were collected from children with signs suggestive of severe disease together with eye, umbilical and pernasal swabs as appropriate. Nasopharyngeal aspirates (NPAs) were collected from children with and without signs of severe disease for identification of viruses and Chlamydia trachomatis by direct fluorescent antibody staining. RESULTS: 3280 infants were triaged and 2168 enrolled, among whom 968 had signs suggestive of severe disease. Group A Streptococcus (Streptococcus pyogenes) and Staphylococcus aureus were the most important bacterial pathogens isolated from children < 1 month old with severe infections, and Streptococcus pneumoniae, S. pyogenes and Staphylococcus aureus were most important in older children. Of 292 eye swabs 19 (7%) grew Neisseria gonorrhoeae. Of 116 umbilical swabs 51 (44%) grew S. pyogenes and 45 (39%) grew Staphylococcus aureus. Respiratory syncytial virus was the most important viral cause of acute lower respiratory infection. CONCLUSIONS: S. pyogenes, S. pneumoniae and Staphylococcus aureus are important causes of severe infection in young children in the PNG highlands. It is necessary to improve access to clean water, promote hand-washing in the hospital and at home and investigate further the use of maternal immunization for the prevention of severe disease in young infants.

High rates of Chlamydia trachomatis infections in young Papua New Guinean infants.

OBJECTIVE: Determine the importance of Chlamydia trachomatis in the etiology of severe infection in young Papua New Guinean infants. METHODS: Between March, 1991, and April, 1993, children <3 months old were recruited as outpatients at Goroka Base Hospital, Papua New Guinea, as part of a multicenter study in four developing countries. Children with predefined inclusion criteria were enrolled. C. trachomatis was identified by direct fluorescent antibody staining in nasopharyngeal aspirates (NPAs) collected from children with and without signs of severe disease and eye swabs from children with and without conjunctivitis. Two to three radiologists read chest radiographs without knowledge of clinical and laboratory findings. RESULTS: Of 3280 outpatients seen 2168 enrolled, 955 NPAs were tested for C. trachomatis and 549 chest radiographs were read. Of 210 eye swabs from children with conjunctivitis 57% were positive for C. trachomatis compared with 8% from 167 children with no conjunctivitis. The prevalence of C. trachomatis in NPAs was 9% in asymptomatic children and 18 and 33% in children with nonsevere or severe pneumonia, respectively. C. trachomatis in NPAs was strongly associated with clinically severe pneumonia [odds ratio (OR), 2.91], reduced arterial oxygen saturation (OR 2.58) and radiographic evidence of pneumonia (OR 5.84) and was also associated with pneumococcal bacteremia (OR 3.48). CONCLUSIONS: In Papua New Guinea Chlamydia must be considered as a cause when treating pneumonia in infants, and effective treatment and prevention of sexually transmitted diseases are urgently needed for a number of reasons, including the need to curb high rates of chlamydial infection in women and infants.

Knowledge about sexually transmitted diseases in rural and periurban communities of the Asaro Valley of Eastern Highlands Province: the health education component of an STD study.

Community health education played a major role in a study of sexually transmitted diseases (STDs) and other reproductive tract infections which we conducted in rural and periurban communities of the Asaro Valley near Goroka in the Eastern Highlands Province of Papua New Guinea. We found that most women had little knowledge about STDs, which they often did not realize were sexually transmitted. Even major signs and symptoms were thought to be normal and many women had not sought treatment until irreversible damage was done. Knowledge of the complications of STDs, such as infertility and stillbirth, was also slight in these women. It is apparent that there is a desperate need for more reproductive health education at the community level. In developing our health education methods, we found that simple line drawings of male and female reproductive organs and of people with different signs of STDs proved useful. These were quick and easy to produce from readily available materials. It was important to separate men and women into different groups with educators of the same sex, and to create a very informal atmosphere, encouraging free-ranging discussion. Following health education and sensitive interviewing, almost all the women selected for the community-based study of the prevalence of reproductive tract infections consented to vaginal examination, even if they were asymptomatic. Additionally, many nonselected women requested examination.

PIP: This paper discusses the health education program carried out in the rural and periurban communities of the Asaro Valley in Papua, New Guinea, where knowledge of STDs is low and risky sexual behaviors are extremely common. The educational program seeks to ensure that the participants understand the reasons for the study and to raise their awareness of the transmission, treatment, and prevention of STDs. All members of the village were encouraged to participate in the educational workshop, which included lectures, group discussions, one-on-one health education, demonstrations, and interviews. After training workshops, practice sessions were also organized to assess the effectiveness of the different teaching methods and visual aids used. It was found that simple line drawings of male and female reproductive organs and of people with different signs of various STDs were useful. It was necessary to divide men and women into two groups with educators of the same sex, which created a more relaxed and free-flowing discussion. Considering that a majority of the women had no experience in using condoms, a demonstration of their use and how to put them on using bananas as models was performed. The questions asked by the women during discussions and private interviews proved that their level of biomedical knowledge about STDs and reproductive health was low, as was their knowledge of the anatomy and physiology of the reproductive system. A high frequency of risky behaviors was also observed, including involvement with multiple sexual partners, commonly in men and young women, with condoms virtually never used. Apparently there is a need for widespread community-based sexual and reproductive health education that is responsive to the needs of people living in rural areas.

Arterial oxygen saturation in healthy young infants in the highlands of Papua New Guinea.

To determine the effect of moderate altitude on arterial oxygen saturation (SaO2), pulse oximetry was performed on 302 children aged <3 months attending a clinic in Goroka, Eastern Highlands Province (1584 metres above sea level) for minor ailments or immunization. Respiratory and heart rates were also measured. The overall mean SaO2 was 96%. Comparison between log-transformed means showed that SaO2 was significantly lower in the first month of life than later (p=0.04). 6% of SaO2 values were <92%, which is a practical cut-off for normal SaO2 in this population of highland children aged <3 months. Mean respiratory and heart rates were 50/minute and 145/minute, respectively. After adjusting for age, respiratory rate increased significantly as SaO2 declined (p=0.002). We have thus defined reference values for SaO2, respiratory rate and heart rate in healthy young infants residing in the highlands of Papua New Guinea. Further investigation is needed to determine whether SaO2 is lower in babies when they are asleep and to define reference values for older children in the highlands.

High prevalence of trichomonal vaginitis and chlamydial cervicitis among a rural population in the highlands of Papua New Guinea.

We conducted a community-based study of the prevalence of sexually transmitted diseases in rural and periurban communities in Eastern Highlands Province. We interviewed a stratified random sample of women and men, examined the women for evidence of sexually transmitted diseases (STDs) and collected specimens for diagnosis of syphilis, by serology and dark-field microscopy, gonorrhoea, by Gram stain and culture, chlamydial infection, by polymerase chain reaction (PCR) and direct immunofluorescence (DIF), trichomoniasis, by wet mount, and bacterial vaginosis, by wet mount and Gram stain. The men were tested for chlamydial infection only (first void urine tested by PCR and DIF). 201 women and 169 men were tested. Additionally, adults in the same communities who had not been randomly selected were offered the same services. An extra 243 women and 85 men were tested in this way. The laboratory results confirmed the clinical impression of an extremely high prevalence of STDs in this population. Among those randomly selected, 46% of the women had trichomonal vaginal infections and 26% had Chlamydia trachomatis infections detected by PCR, while 25% of the men had chlamydial infections. Other infections were much less common. 58% had one or more STDs. The prevalence of infection in self-selected adults was similar to that found in those randomly selected.

Screening for sexually transmitted diseases in rural women in Papua New Guinea: are WHO therapeutic algorithms appropriate for case detection?

The presence of a large reservoir of untreated sexually transmitted diseases (STDs) in developing countries has prompted a number of suggestions for improving case detection, including the use of clinical algorithms and risk assessments to identify women likely to be infected when they present to clinics for other reasons. We used data from a community-based study of STDs to develop and evaluate algorithms for detection of cervical infection with Chlamydia trachomatis or Neisseria gonorrhoeae, and for detection of vaginal infection with Trichomonas vaginalis or bacterial vaginosis. The algorithms were derived using data from 192 randomly selected women, then evaluated on 200 self-selected women. We evaluated the WHO algorithm for vaginal discharge in both groups. The prevalences of cervical and vaginal infection in the randomly selected group were 27% and 50%, respectively, and 23% and 52%, respectively, in the self-selected group. The derived algorithms had high sensitivities in both groups, but poor specificities in the self-selected women, and the positive predictive values were unacceptably low. The WHO algorithms had extremely low sensitivity for detecting either vaginal or cervical infection because relatively few women reported vaginal discharge. Simple algorithms and risk assessments are not valid for case detection in this population.

Community based study of sexually transmitted diseases in rural women in the highlands of Papua New Guinea: prevalence and risk factors.

OBJECTIVE: To estimate the prevalence of sexually transmitted diseases (STDs) and determine their risk factors/markers among a rural population of women in the highlands of Papua New Guinea. METHODS: Community based random cluster sample of women of reproductive age were interviewed and examined and had specimens collected for laboratory confirmation of chlamydial and trichomonal infection, gonorrhoea, syphilis, and bacterial vaginosis. RESULTS: Chlamydia trachomatis was detected in 26%, Trichomonas vaginalis in 46%, Neisseria gonorrhoeae in 1%, syphilis in 4%, pelvic inflammatory disease (PID) (diagnosed clinically) in 14%, and bacterial vaginosis in 9% of 201 women. 59% of the women had at least one STD. In a multivariate logistic regression analysis taking the clustered sampling into account, independent risk factors for chlamydial infection were age < or = 25 years, < four living children, visualization of yellow mucopurulent endocervical secretions on a white swab, and bacterial vaginosis. Being married to a man who did not have other wives was protective. For trichomonal infection, independent risk factors were having no formal education, infertility, more than one sexual partner in the previous 12 months, treatment for genital complaints in the previous 3 months, abnormal vaginal discharge detected on examination, and chlamydial infection. Similar levels of trichomonal infection were found in all age groups. Among married women, rates of infection correlated with their perception of their husband having had other sexual partners in the previous 3 months, and this relationship was significant for chlamydial infection among women over 25. CONCLUSION: STDs are a major problem in this population, with the risk factors varying by outcome. Current treatment regimens are inappropriate given the high prevalence of trichomonal infection, and the available services are inadequate. Effective interventions are required urgently to reduce this burden and to prevent the rapid transmission of HIV.

Bacterial, viral and parasitic aetiology of paediatric diarrhoea in the highlands of Papua New Guinea.

Enteropathogens and clinical features associated with diarrhoea were investigated in 1526 children admitted over a 5-year period to the paediatric ward of a hospital in the highlands of Papua New Guinea. Overall, a recognized pathogen was isolated from 39 per cent of the children admitted with diarrhoea. The most commonly isolated agents were rotavirus (23 per cent), Shigella spp. (13 per cent), Campylobacter spp. (12 per cent), Cryptosporidium parvum (10 per cent) and enteropathogenic Escherichia coli (8 per cent). The clearest clinical associations were rotavirus with vomiting, and Shigella with blood and pus in the stool. A control series of children admitted with other complaints was also included, and the odds ratios for diarrhoea for the above five pathogens were 18.2, 9.6, 3.7, 2.2, and 1.6, respectively.